Provider Demographics
NPI:1144375866
Name:SOUTHERN ILLINOIS EYECARE, PC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS EYECARE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:SOELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-826-4521
Mailing Address - Street 1:520 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1889
Mailing Address - Country:US
Mailing Address - Phone:618-443-5252
Mailing Address - Fax:
Practice Address - Street 1:520 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1889
Practice Address - Country:US
Practice Address - Phone:618-443-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS EYECARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047931268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
707400Medicare PIN
3979170001Medicare NSC
CH6847Medicare PIN